Costs of Planned Home vs. Hospital Birth in British Columbia Attended by Registered Midwives and Physicians
Costs of Planned Home vs. Hospital Birth in British Columbia Attended by Registered Midwives and Physicians
Patricia A. Janssen 0 1
Craig Mitton 0 1
Jaafar Aghajanian 0 1
0 1 School of Population and Public Health, University of British Columbia , Vancouver, British Columbia , Canada , 2 Child and Family Research Institute , Vancouver, British Columbia , Canada , 3 Centre for Clinical Epidemiology and Evaluation , Vancouver, British Columbia , Canada , 4 BC Centre for Epidemiologic and International Ophthalmology , Vancouver, British Columbia , Canada
1 Editor: Sari Helena Räisänen, Kuopio University Hospital , FINLAND
Competing Interests: The authors have declared
that no competing interests exist.
Home birth is available to women in Canada who meet eligibility requirements for low risk
status after assessment by regulated midwives. While UK researchers have reported lower
costs associated with planned home birth, there have been no published studies of the
costs of home versus hospital birth in Canada.
Costs for all women planning home birth with a regulated midwife in British Columbia,
Canada were compared with those of all women who met eligibility requirements for home birth
and were planning to deliver in hospital with a registered midwife, and with a sample of
women of similar low risk status planning birth in the hospital with a physician. We
calculated costs of physician service billings, midwifery fees, hospital in-patient costs,
pharmaceuticals, home birth supplies, and transport. We compared costs among study groups
using the Kruskall Wallis test for independent groups.
In the first 28 days postpartum, we report a $2,338 average savings per birth among women
planning home birth compared to hospital birth with a midwife and $2,541 compared to
hospital birth planned with a physician. In longer term outcomes, similar reductions were
observed, with cost savings per birth at $1,683 compared to the planned hospital birth with
a midwife, and $1,100 compared to the physician group during the first eight weeks
postpartum. During the first year of life, costs for infants of mothers planning home birth were
reduced overall. Cost savings compared to planned hospital births with a midwife were
$810 and with a physician $1,146. Costs were similarly reduced when findings were
stratified by parity.
Planned home birth in British Columbia with a registered midwife compared to planned
hospital birth is less expensive for our health care system up to 8 weeks postpartum and to one
year of age for the infant.
Recent large population-based studies using standardized third-party ascertainment of
outcomes have affirmed the safety of planned home vs. planned hospital birth attended by
regulated midwives or physicians among selected women.[1–4] The desirability of the choice to
give birth at home has been supported in both quantitative [5–7] and qualitative [8–12] studies.
In Canada, planned home birth attended by regulated midwives was first introduced in 1994 in
the province of Ontario, where the number of home births has risen to 3,000 annually. In
British Columbia, 11% of births are currently attended by midwives. Among these,
approximately 20% take place at home.
The only Canadian evaluation of costs of out of hospital birth to date evaluated free standing
birth centres in Quebec. This study suggested that midwifery care in Quebec birth centres
differs little from conventional medical care in terms of costs. An American study reported
average costs in 1991 to be $1,711 for home births and for hospital births $5,382. In the
Netherlands, where 29% of births are planned to be at home with regulated midwives, a recent
prospective study of healthy primiparous women reported a decrease in cost of 177 Euros
associated with home versus hospital birth. A 2008 review of economic implications of out of
hospital births was unable to report definitive conclusions due to the paucity of economic
literature relating to home birth, but concluded that home birth is likely to be a cost-effective
option. Most recently the Birthplace in England Collaborative Group, reporting on a
sample of home births attended by midwives, midwifery units and in-hospital obstetric units,
concluded that planned home birth was the most cost effective option for women at low risk of
pregnancy complications. In the current study, we present a detailed economic analysis of
all home births attended by regulated midwives in the Province of British Columbia, Canada.
The current study undertakes a government payer perspective to compare costs of planned
home birth attended by regulated midwives with those of planned hospital births attended by
regulated midwives and by physicians. Details of the study are presented elsewhere. In
brief, costs for all women planning home birth with a regulated midwife between 2001 to 2004
in British Columbia, Canada were compared with those of all women who met eligibility
requirements for home birth as defined by the College of Midwives of BC  and were
planning to deliver in hospital with a registered midwife, and with a random sample of women of
similar low risk status matched on age, parity, marital status, and year of birth, and planning
birth in hospital with a physician.
Linked data was obtained for this study from Population Data BC. Population Data BC is a
health data resource linking heath data through a unique 10-digit personal health number
assigned to all subscribers of the British Columbia Medical Services Plan (MSP). All BC
residents must enroll with MSP. Personal health numbers for individuals designated to each of our
study cohorts defined from the BC Perinatal Data Registry were linked to five health data
BC Perinatal Data Registry
Discharge Abstract Database
Personal Health Numbers; maternal and newborn characteristics,
pregnancy and birth information.
Services provided by fee-for-service practitioners to individuals covered
by British Columbia’s Medical Services Plan, and codes for service fees.
Information on Medical Services Plan registration.
Mode of emergency transport, air or ground, and cost estimates for
Case Mix Groups and Resource Intensity Weights for each individual
who was discharged or transferred from an acute care hospital in BC.
The ingredient cost of drugs, professional fees, and third-party costs
(administrative costs of adjudicators/employers).
registries: Medical Services Plan Payment Information; and its associated Registration and
Premium Billing file; BC Ambulance Service; Discharge Abstract Database; and
This study was undertaken with approval from the University of British Columbia Research
Ethics Board, the Children's and Women's Health Centre of British Columbia Research Review
Committee, the British Columbia Ministry of Health Services, and the British Columbia
College of Pharmacists.
The Medical Services Plan (MSP) Payment Information file contains data on services
provided by fee-for-service practitioners to individuals covered by MSP, BC’s universal insurance
program (Table 1). We assigned costs associated with fee payments to physicians by summing
the amount for fee item codes specific to maternity services associated with each patient’s
personal health number in the MSP records. Midwives bill the Medical Services Plan for a set fee
for each proportion of a course of midwifery care, as opposed to specific maternity codes, as all
of their service is related to maternity care. For our analysis of birth to 28 days postpartum, we
allocated 100% of the fee schedule for labor/delivery for deliveries conducted at home by
midwives. We allocated 40% if the midwife attended the birth in hospital but did not deliver the
baby (after transfer of care to a physician) and 0 if the midwife was not in attendance, as per
MSP protocol. We allocated two thirds of the cost of a course of postpartum care for 28 days if
the midwife billed for postpartum care. For our analysis of birth to 56 days (8 weeks) we
similarly assigned costs of labour/delivery and allocated 100% of the postpartum component of
care. Tota costs from which proportionate costs were derived were obtained from the Medical
Services Payment Plan.
Mode of emergency transport, air or ground, was obtained from BC Ambulance Service
data files obtained by Population Data BC. In consultation with BC Ambulance Service,
(personal communication D. Andrusiek, Research Director, Medical Programs, Emergency and
Health Services Commission of BC Ambulance Service), ambulance costs were attributed as
follows: $500 for ground, $1000 for air, and $1500 for a combination of air and ground. If
transport included both mother and baby, the cost is listed for the infant only.
The Discharge Abstract Database houses data on discharges, transfers and deaths of
inpatients and day surgery patients from acute care hospitals in BC. The hospitalization cost was
derived by multiplying the In-Patient Resource Intensity Weight (P-RIW) by the Cost Per
Weighted Case (CPWC) for the corresponding site and fiscal year. The RIW measures the
intensity of resources used based on patient diagnosis, surgical procedure performed and the
case mix group assigned to the individual patient. Case mix is an inpatient grouping
methodology used in Canada to create discrete clusters of patients using clinical, administrative
and resource consumption data. The case mix group takes into consideration the patient’s age,
health status, and discharge status. The result is groups of patients that are clinically similar
and/or homogeneous with respect to hospital resources used. The Canadian Institute for
Health Information (CIHI) defines RIWs for case mix groups. RIWs for individuals are
available from the Discharge Abstract Database. To convert the RIWs into actual dollars, the RIW
is multiplied by the CPWC. When the total expenditures for inpatient care in a particular acute
care hospital for one year is divided by the total weighted cases of the same hospital during the
same year, the result is the average cost of providing care to a patient with a weighted case
value of 1.00. Thus, the CPWC is the cost of a stay with a weight of 1.00. The CPWC is different
for each hospital each year. Province-wide CPWCs for the study period were obtained from
the BC Ministry of Health. We applied the CPWC value specific to each year and each hospital
when computing costs.
PharmaNet records all prescriptions dispensed by British Columbia pharmacists in an
outpatient setting. PharmaNet is administered by the British Columbia Ministry of Health for
residents of BC. PharmaNet records include the ingredient cost, professional fees, and third-party
costs (administrative costs of adjudicators/employers). Records also include non-drug items
such as diabetic test strips. Cost data was not available for residents paid through federal plans,
including federal police officers, veterans or individuals funded through Indian Affairs, but
‘quantity dispensed’ and ‘days supply’ was available and corresponding costs were estimated
from provincial costs for these entities.
To capture costs associated with the intrapartum period, we included costs from all data
sources for the 48 hour period before the date and time of birth for the mother. In our first
analysis, we included maternal costs until and including 28 days postpartum to correspond to
the completion of the neonatal period for the baby (Mom -2 to +28, Baby +28). Our second
framework for comparison was the postpartum period for the mother, defined as 8 weeks or 56
days, and the first year of life or 365 days for the infant (Mom -2 to +56, Baby +365). To
exclude births by non-BC residents, all mothers included had to be registered with the
provincial medical services plan during the follow-up period.
We excluded from our analysis, 217 mother-baby pairs in which the babies had one or more
ICD-10 codes for congenital malformations. After removal of one birth with data entry errors,
and 19 births in hospitals where the cost per weighted case (CPWC) was not available, the
study population comprised records related to 9,864 live births.
We compared costs among study groups using the non-parametric Kruskal Wallis test for
independent samples, as distributions were not normally distributed. We report mean costs
per group, and groups stratified by parity. The data were analysed using SAS software (version
9.3, SAS Institute, Cary, N.C.)
In total our study sample included 9864 women: all women who planned a home birth with a
regulated midwife (n = 2243); all planned hospital midwife-attended births meeting the
eligibility requirements for home birth (n = 3610) and a sample of women planning hospital birth
with a physician, also meeting eligibility requirements for home birth and matched on age
category, parity, and restricted to hospitals in which midwives had admitting privileges (n = 4011).
Comparison groups were similar with respect to age, lone parent status, income quintile, BMI,
use of substances and gestational age at start of prenatal care (Table 2).
During the initial 28 days postpartum, average costs per mother were significantly reduced
among women planning home birth compared to hospital birth, planned either with a midwife
or a physician (Table 3). Compared to those who planned hospital birth with a midwife,
provider fees, hospital charges, and pharmaceutical costs were significantly less. Compared to
planned hospital births with a physician, provider fees and transport costs were higher and
hospital costs and pharmaceutical costs were less. Similarly, average costs per newborn during
this period, corresponding to the early neonatal period, were significantly reduced in the home
birth group. Provider fees and pharmaceutical costs were lower in the home birth group
compared to both planned hospital birth groups. Our data indicate a $2,338 average cost savings
per birth among women planning home birth compared to hospital birth with a midwife and
$2,541 compared to hospital birth planned with a physician.
Our findings were similar among nulliparous women, for whom overall average costs
among women planning home birth were significantly reduced by $2,122 and $2,518 for
planned hospital birth with a midwife and physician respectively (Table 4). Among
multiparous women, corresponding cost savings were $2,307 and $2,579 per birth (Table 4).
During the first 56 days, corresponding to the eight week postpartum period, maternal costs
for women planning home birth were significantly reduced overall and for sub-categories of
hospital and pharmaceutical costs. Costs for transport were higher in the home birth group.
Costs savings per birth were $1,683 compared to the planned hospital birth with a midwife,
and $1,100 compared to the physician group (Table 5).
For nulliparous women these cost savings were $1,514 and $1,133 and for multiparous
women $1,679 and $1,095. (Table 6).
During the first year of life, costs for infants of mothers planning home birth were reduced
overall, and for physician fees and pharmaceutical costs compared to both planned hospital
cohorts. Cost savings compared to planned hospital births with a midwife were $810 and with
a physician $1,146 (Table 5).
Costs were similarly reduced when findings were stratified by parity. Cost savings among
infants of primiparous women were $749 and $1,095 for hospital births planned with a
midwife and physician respectively and for infants of multiparous women were $802 and $1,186
Our study demonstrates a significant cost savings for planned home birth in British Columbia
with a regulated midwife compared to planned hospital birth, either with a regulated midwife
or with a physician. As expected, transport costs were higher for mothers in the home birth
group, but provider fees, hospital costs and pharmaceutical costs were lower for both mothers
and infants. We would expect hospital costs to be lower since most women in the planned
home birth would not be admitted to hospital. Provider fees and pharmaceutical costs are
reduced in both midwifery cohorts compared to the physician group and likely reflect both the
reduced rates of interventions among women receiving care by midwives, and, since these
differences persist beyond 28 days, self-selection to planned home birth of women who are
particularly healthy and do not wish to have pharmacological interventions during labour and birth.
This is the first study of home birth to extend analysis of cost to the conclusion of the
postpartum period for mothers and to one year for infants. This is noteworthy because “hidden” risks
of home birth, that is morbidity manifesting beyond the immediate postpartum period, if it
Planned Home Birth
n = 926
Planned Hospital Birth
n = 1797
Planned Hospital Birth
n = 1619
existed, would be reflected in higher costs during the prolonged period of observation in this
study. However, delayed morbidity does not appear to be a consequence of home birth.
Due to differences in how costs are assigned across studies and countries, our findings may
be cautiously compared to those of Hendrix et al. in the Netherlands, comparing costs of births
to nulliparous women planning birth at home with a regulated midwife versus women
planning birth in short stay units attended by either midwives or family practice physicians.
The study examined 100 midwifery practices sampled at random from across the Netherlands.
Costs for provider fees, hospital, and transport from the intrapartum period to six weeks
postpartum were €339 ($495 Cdn) less in the planned home birth group. This analysis, however,
does not separate births attended by midwives and physicians.
A cost analysis of home birth from Washington State, USA during the same time period as
ours, reported cost savings of $2,971 for planned home births attended by licensed midwives
vs. planned hospital births resulting in vaginal delivery attended by midwives and $5, 550 for
hospital births attended by midwives resulting in cesarean delivery. These differences, which
correspond only to the intrapartum period, are larger than ours, but again must be viewed
cautiously as costs in a Canadian context do not necessarily align well with costs (or charges)
reported in US studies.
A British study reporting on 142 of 147 regional health authorities (“trusts”) estimated costs
for provider fees and salaries, hospital, transport and pharmaceutical costs from finance
departments of participating trusts, consultations with midwives, and national sources of data.
The mean savings for home births (maternal and newborn) during the intrapartum period
versus obstetrical units was £564.6 ($1073.93 Cdn).
Strengths of our study include complete ascertainment of planned home and of hospital
births attended by midwives in an entire province. The same midwives attend both home and
hospital birth in British Columbia since they are required to offer eligible women the choice of
either setting. Our comparison of home vs. hospital in the midwifery groups therefore reflects a
true comparison of place of birth un-confounded by type of caregiver. Both midwifery groups
and our random sample of physician-attended birth were of comparable low risk status. We
report costs assigned to individual hospitals within each study year, accounting for potential
confounding by hospital size and location. In addition, our period of observation was longer
than reported in the literature to date. Our study is limited by our inability to ascertain actual
transport costs, although the proportion of costs for transportation was less than one percent
of all costs. More importantly, our hospital costing data is limited to membership in case mix
groups rather than individual costs as individual costing data is not collected by hospitals in
BC. The number of case mix groups that can be assigned to mothers is 25 and to infants 31,
however, indicating a wide range of designations for complexity. We were also unable to
include costs incurred due to lost productivity, although it might reasonably be expected that
differences between our groups would not be observed. In addition, our data do not include
costs from long term morbidity such as neurological sequelae that may not have manifested in
the first year of life.
Planned Home Birth
n = 926
Planned Hospital Birth
n = 1797
Planned Hospital Birth
n = 1619
We conclude that planned home birth in British Columbia with a registered midwife compared
to birth planned for hospital with a registered midwife or a physician is less expensive for our
health care system for mothers up to 8 weeks postpartum and infants up to one year of age.
Our findings should reassure health planners and policy makers that there are not deferred
excess costs associated with planned home birth with a registered midwife and encourage
home birth in similar settings as a choice for healthy women.
S1 Fig. Janssen Home vs Hospital Birth Outcomes paper.
Conceived and designed the experiments: PJ CM. Performed the experiments: PJ JA. Analyzed
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Consolidation File (MSP Registration & Premium Billing). V2 [Internet]. Population Data BC. Data
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